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problem. We are having some very promising results at the family level, at the community level, as well as at the peer level, in attempting to address the specific problems.
DRUG ABUSE PREVENTION
Dr. SCHUSTER. As Dr. Johnson commented, the National Institute on Drug Abuse has been involved in primary prevention research which has clearly demonstrated that to be effective in primary prevention-that is, to prevent drug initiation, to prevent the experimentation with drugs-it is essential that programs be comprehensive.
We have recently completed an analysis of two major city programs with all the appropriate controls and shown that those children who are part of a multifaceted program which included the family, which included the teachers, which included the family by virtue of, for example, homework assignments from school, which involved the local business community, which involved the local police not only in supply-side reduction activities but as well in demand-reduction activities, this type of total commitment, gave rise to a change in the normative values of that community.
That is what is key, because for a 24-hour-a-day period, children in this program were being given the same consistent message by all community contacts that they would have, both in the family, the school, and the media. That is what is essential.
That is for primary prevention, but in addition, we are very concerned about the issue of secondary prevention. That is, those people who experiment with drugs, who escalate and go on to abuse and dependence, and we are conducting studies to determine what are the early factors that we can identify that give rise to a vulnerability to not only experiment with drugs but to go on to addiction.
We now believe we have some factors that we can identify as early as the first grade which place individuals at greater risk for becoming drug abusers in adolescence as well as having a number of other behavioral disorders at that time. We hope, then, on the basis of being able to identify what these early risk factors are, to be able to develop appropriate interventions.
Dr. GOODWIN. I think we might say in general that some of the broader-based prevention programs are successful. If we look at our mainstream population, which are that successful core of Americans who graduate from high school, we see very encouraging longterm trends. That is, very substantial reduction from the peaks that we had in drug addiction back in the early 1980's.
We have seen a 72-percent drop in 30-day or regular cocaine use. That is a very important drop. However, that means that our prevention efforts now are shifting more and more to those high-risk populations that are not changing as much—the pockets of vulnerability, as we call them—and there, the research base is even more important to focus those programs appropriately.
Dr. PRIMM. Dr. Johnson spoke about primary prevention, and, of course, Dr. Schuster spoke about secondary prevention, and treatment is always seen as tertiary prevention. Every time we treat
one person for substance abuse we eliminate that individual from trying to gain support for that behavior which is deleterious by transferring it to another individual, so tertiary prevention is what treatment is all about.
In treatment programs we often have family therapy since siblings are likely to also be involved in substance abuse behavior. If there is one member of the family involved in treatment then, that in itself, of course, cuts down the possibility of the spread of substance abuse, whether it be alcoholism or other substances abuse. So, again; treatment is tertiary prevention.
PREVENTION OF MENTAL ILLNESS
Dr. LESHNER. At NIMH, we basically have taken a three-pronged approach to our rather rapidly growing prevention portfolio:
One has been to support studies that are involved with direct interventions designed to prevent specific disorders.
The second category are more broad-based interventions, particularly early in life, looking at high-risk individuals that might affect a broad range of outcomes. That is, a broad range of disorders.
The third category are a variety of educational activities that we do that are involved in secondary prevention or primary prevention.
It is an area that has been growing quickly for us. We now have five major prevention intervention research centers. In addition, we have a number of prevention research demonstrations that were begun last year, and a rather extensive and diverse research portfolio.
PREVENTION OF ALCOHOL ABUSE
Senator HARKIN. Dr. Gordis.
Dr. GORDIS. Our prevention research efforts are focused both on individual grantees as well as one of our 14 research centers which is devoted solely to issues of prevention. Our work is in many spheres.
Since alcohol is a legal drug, obviously there is research to be done on issues of social policy and legislation and the impact of such, and so we have research on the economic modeling of the response of consumption to price, on elasticity-how consumption responds to price on the effect of advertising, on the question of whether drinking is initiated in the young, on server intervention programs, on drinking driver laws, and on the effect of age limitations on alcohol consumption on both the driving and the cirrhosis death rates.
As far as individual studies, we have longitudinal studies showing the mix of genetic and environmental and family relationship factors as kids move from one age of risk to another, and that is a very large area of our prevention portfolio right now.
The genetics work will pay off, I think, in identifying high-risk youth who are candidates for better-targeted intervention. We also have warning label studies now, which are studying the effect of the warning label legislation passed by Congress 2 years ago to see whether it is modifying knowledge and behavior.
We have prevention in the AIDS area, to see whether within alcohol treatment programs the kind of prevention that could be done within those programs is going to cut down on the conversion to sero-positivity.
Finally, we have a collaborative prevention announcement now with the Office for Substance Abuse Prevention-it is sponsored by both NIAAA and OSAP-to study a mixture of cities to see whether the type of community trials which have been done before in cardiovascular disease can be duplicated in the alcohol world to see which efforts within the community are best suited to reducing the hazards and the dangers of alcohol consumption.
TREATMENT OUTCOME RESEARCH
Senator HARKIN. Very good. Thank you all-good briefing.
Moving from prevention to intervention, what can you report on the progress of treatment outcome research in improving ways of matching patients to the most appropriate substance abuse treatment program?
Dr. GOODWIN. Perhaps Dr. Gordis could talk about some treatment matching in the alcohol arena, and then I will make some general comments.
Dr. GORDIS. The question is of paramount importance to the treatment world, because obviously, if we can type the treatment specifically and also describe the kinds of patients who are suited to them, we will reduce the cost of treatment, maximize its efficiency, and cut down the inconvenience to both staff and patients.
We are very proud of our two big collaborative studies, one of which is on that issue. The patient-treatment matching study, which is now into its second year, is conducted in nine different centers in order to get an adequately large and diverse population.
Essentially, there are three arms of treatment. In one, the conventional treatment with traditional counseling and therapy approaches and so on is a big component. Another one has to do with the cognitive behavioral modeling, and a third arm of treatment is the equivalent of minimal intervention for less dependent people, and a mix of theories are being tested as to which type of patients are suited for this.
This program is underway. The pilot studies are beginning, and we hope within several years we will have some interesting information which will affect the whole treatment community.
Senator HARKIN. It will take several years, though?
Senator HARKIN. What has research shown on other treatments, such as acupuncture?
Dr. GORDIS. I think the data on acupuncture must be still considered inconclusive. Most of the literature on acupuncture, I think, would not pass muster as far as the standards of rigorous analysis that we demand in all areas of health care now.
One or two of the studies have been more promising and have really satisfied some of those standards, but they have been small, and so we are welcoming applications to test this further.
I think we do not know the answer yet.
Dr. GOODWIN. NIDA is doing some studies on acupuncture. Do you want to comment on that?
Dr. SCHUSTER. We have two studies of acupuncture currently ongoing for the treatment of cocaine addiction. I must say that I would agree with Dr. Gordis that at least in one of them the results to date have not proven to be any better than for individuals who became engaged in other kinds of activities for a comparable amount of time. In other words, it was program involvement rather than the acupuncture which seemed to be responsible for any changes that took place.
EFFECTIVE SUBSTANCE ABUSE TREATMENT
Dr. GOODWIN. Could I perhaps make a couple of general comments about substance abuse treatment, because that often is misunderstood.
First, I will just repeat something Dr. Primm frequently says, which is that drug abuse and alcohol abuse are chronic relapsing diseases, and they should be thought of like we think of arthritis or like we think of hypertension. That is, you have episodes, you have a chronic vulnerability.
Second, the treatment varies enormously with the individual, such as whether they do or do not have a coexisting mental disorder, such as whether they are highly motivated.
It is one thing for drug abuse to be occurring in a very successful lawyer who could lose his whole practice if he does not get straight. It is quite another for drug abuse to be occurring in somebody who seems to feel that they have nothing to lose. It makes a big difference whether they have anything to be rehabilitated for, or whether, as Dr. Schuster says, they need to be habilitated in the first place. Another factor is that there might well be very little self-esteem structure there after you get rid of the drug problem.
All studies indicate that the longer people stay in treatment_of a variety of types, the more effective it is. However, the more arduous treatment strategies require more commitment by the patient, and, therefore, they have higher dropout rates.
We do have some evidence on what the components of a good treatment system are. We know that if you have a stable staff, if you provide educational and vocational counseling along with your drug counseling, if you have a staff-client match in terms of racial and ethnic characteristics, if you have strong leadership, these all have been shown to substantially increase the effectiveness of any given treatment, and Dr. Primm is incorporating those standards into his treatment improvement programs.
We also have data from a NIDA researcher, Chuck O'Brien, at the University of Pennsylvania, showing that a high-intensity treatment can have three times more effect in keeping people drug free than a low-intensity program, even though the cost is only double. That is, if you have a twice-as-expensive treatment which includes psychiatric care, employment counseling, and high _intensity of counseling, which costs twice as much as the stripped-down version, it nevertheless provides three times more effectiveness both in terms of drug behaviors and risk of getting AIDS if you happen to inject drugs.
So that if you look across the spectrum, you have out-patient programs, you have in-patient detoxification programs, you have medication-based programs-methadone is the best established. We know that methadone works about 70 percent of the time, if it is done well. We have tricyclic antidepressants for cocaine, still experimental. We have buprenorphine, which is a very exciting new development that NIDA has data on that may well prevent some of the craving for cocaine as well as for heroin, but these are still considered experimental.
I would say the overall treatment success in drug abuse and alcohol is approximately equivalent to what it is now with some of the difficult cancers that we deal with. That is to say, we have overall an effective rate if you count good programs, poor programs, not highly motivated individuals. Overall about one-third of the clients who go into these treatment systems come out and stay clean, but two-thirds do not, and compared to some areas of medicine, that is not bad. Compared to other areas, we have a long way to go.
PSYCHOTHERAPY AND CHRONIC DISEASE
Senator HARKIN. I have a couple of questions. I will just ask one more before I turn to Senator Bumpers, and perhaps this should go to Dr. Leshner.
I asked a question again this morning about nonconventional means of treatment, investigating, and researching nonconventional means of treatment. I just mentioned one here, acupuncture, and the response was it needed more looking at, and you needed to set up better scientific analysis of it.
My question for you is, there have been some recent articles about psychotherapy being shown to help cancer patients, and I am wondering if you have any knowledge of that, and can you comment on that at all?
Dr. LESHNER. I am familiar with the study that was done. I can give you a more detailed explanation of that for the record, but a study was done recently by one of our investigators that showed that the duration of survival for breast cancer patients was enhanced following group psychotherapy treatment.
Senator HARKIN. That is interesting. The longevity, you say, the survivability, was increased?
Dr. LESHNER. That is right, yes.
Dr. GOODWIN. It is a function of how early the intervention is done, because the apparent mechanism of this relates to the control by the brain of the immune system, but but the so-called psychoimmunological control mechanisms work better-the immune system's control of cancer works better early in the development of some cancers. If you study them very late when they are in the hospital, there is very little effect.
Senator HARKIN. There is still a lot we have got to learn about that interaction between the brain and
Dr. LESHNER. That is right. right. We We have an extensive psychoneuroimmunology research program going, looking at that interface between brain, immune, and endocrine systems.
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